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Novel Carpal Tunnel Release Decision Tool Guided by Multi-Criteria Decision Analysis Incorporating Patient-Reported Outcomes, Complications, and Cost
Casey Imbergamo, MD
1; Gongliang Zhang, PhD, MS
1; Gabriel Yohe, MS
1; Fong Allan, MS
2; Aviram M. Giladi, MD, MS
31The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; 2Curtis National Hand Center, Baltimore, MD; 3The Curtis National Hand Center, Baltimore, MD
Introduction: The purpose of this work was to develop a Multi-Criteria Decision Analysis (MDCA) model guided in part by early post-operative patient-reported data to compare open (OCTR) versus endoscopic carpal tunnel release (ECTR), and to create an interactive platform to implement in the shared decision-making process. We hypothesized that with all variables weighted equally, OCTR would be the preferred procedure, owing primarily to its lesser cost.
Materials & Methods: A retrospective review of patients who underwent OCTR or ECTR at a single institution from 2018-2023 was performed. Patient reported outcomes (PROs) data used in this study to reflect early post-operative experiences/value were collected at the two-week postoperative timepoint, including Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE), Pain Interference (PROMIS PI), and visual analog scale (VAS) pain scores. Institutional financial data were used to determine the average total payments and direct costs to patients. Complication data including infection, transient nerve injury (TNI), permanent nerve injury (PNI), and recurrence following CTR were pulled from the existing literature. MCDA modeling then was used to determine the best value for surgical treatment of carpal tunnel syndrome. The MCDA model was converted into an interface whereby patients and providers can manually adjust weights for each variable based on individual priorities.
Results: 908 patient encounters (807 ECTR, 101 OCTR;10 providers that perform ECTR, 3 that perform OCTR) were including for dataset modeling. Table 1 outlines the data that were incorporated into the MCDA model. When preferentially weighting TNI, recurrence, or patient cost as variables of importance, OCTR is the preferred procedure. When preferentially weighting PNI, infection, or VAS scores, ECTR is the preferred procedure. The [blinded] Carpal Tunnel Decision Matrix was subsequently created in order to provide real-time results as the weight of each variable is adjusted (Figure 1).
Conclusions: OCTR is preferred for patients who want to minimize cost, or prioritize avoidance of TNI or recurrence of disease. ECTR is preferred for patients who prioritize decreased pain in the early postoperative period, or avoidance of infection or PNI. The [blinded] Carpal Tunnel Decision Matrix is an interactive tool that can be incorporated into shared-decision making in real-time. Further research with this tool is ongoing.
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